A forensic psychiatrist who is often called on to
conduct mental competency evaluations of elderly individuals
advises colleagues on the dos and don’ts of such
assessments.

Courts often turn to psychiatrists, particularlyforensic
psychiatrists, to ascertain whether an elderly personis
competent. What judges often don’t understand, however,is that "not all competencies are created
equal," accordingto Carla Rodgers, M.D. Thus,
defining where a person is on thecontinuum from
"outspoken to outrageous" becomes a complex
undertaking.

Speaking at the annual meeting of the American College of
ForensicPsychiatry last month in Rancho Mirage,
Calif., Rodgers urgedpsychiatrists who conduct
competency evaluations to rely ontheir senses of
sight, smell, touch, and hearing to fill ina
substantial number of the competency evaluation blanks.

Vital clues can first be gleaned from closely observing an
elderlyevaluee, she pointed out—for example, by
determining whetherthat person looks at the
psychiatrist upon being introducedand whether the
individual’s eyes track with the psychiatrist’smovements.
Rodgers also advised assessing the evaluee’s"body
habitus," that is, whether there is any body wasting
evident,signs that the person has been leaning
against a chair’sarm for unacceptably long
periods of time, and whether the person’sdental
hygiene is adequate or is a sign of deterioration. "Teethdon’t get rotten overnight," said Rodgers, a
consultation-liaisonpsychiatrist in Philadelphia
and clinical assistant professorof psychiatry at
Robert Wood Johnson Medical School.

She also advised psychiatrists to pay attention to an
evaluee’sfacial expression, grooming such as
nail care, and clothing.Clothing that is
disheveled or rife with food stains could besigns
of a loss of mental competence.

And don’t forget your nose, she stressed. A psychiatristcan gain important competency information by using his
or hersense of smell. Pay attention to what the
evaluee and the roomsmell like, Rodgers said, and
if foul smells are pervasive,how the individual
responds to those odors. In addition, takenote of
whether the person smells of smoke, alcohol, or evenmarijuana,
the last of which may be a clue as the baby-boomgeneration
enters "seniorhood," she suggested.

Touch should come into play in an assessment of skin turgor
(tone),Rodgers said.

As for hearing, she urged psychiatrist evaluators to listenfor wheezing and hoarseness and, though it may seem
basic, whetherthe person can hear what the
psychiatrist is saying, which includes"checking
to make sure hearing aids are actually turned on."

A panoply of signs and symptoms may appear to signal the
lossof mental competency in elderly individuals,
but in fact areevidence of other problems, some of
which may be amenable totreatment, Rodgers said.
Among the conditions critical to evaluate, she noted, are
dementiaof either the Alzheimer’s or vascular
type; alcohol-relateddementia, "which is
often overlooked"; depression, which canappear
as "pseudo-dementia"; confusion that may be
secondaryto medications, a common finding in
elderly nursing-home residents;and physical
incapacitation manifest by inability to see, hear,or
speak, immobility, or excretory issues, which Rodgers
describedas the "three P's—pee, poop, and
puke." These can be "redflags" for
incompetence, but should not be considered conclusiveproof,
she noted.

She emphasized that any comprehensive geriatric competency
evaluationdepends on three things—"time,
time, and time." That theevaluee is elderly
and may show signs of dementia does not meanthe
evaluation should be a "rush job," she said.

Rodgers also urged psychiatrist evaluators to obtain as
muchcollateral data as possible. These should come
from the evaluee’smedical charts and laboratory
reports, hospital and nursing-homestaff or other
caregivers, family members, the attending physician,and
other consultants.

Throughout a competency evaluation the psychiatrist should
keepin mind the specific type of competency at
issue. If, for example, competency to make a will is being
assessed,key issues evaluators need to assess
center on whether the elderlyperson knows who his
or her natural heirs are and the natureand extent
of the estate involved.

Evaluating a person’s competence to make medical
decisions,in contrast, requires that the
individual know what is wrongwith him or her and
who is doing the treating, as well as understandthe
proposed treatment in general terms and the risks and benefitsof that treatment compared with receiving no treatment,
Rodgersexplained.

And do not overlook an exploration of the family’s
motivesin requesting a competency evaluation, she
cautioned. Do familymembers have reason for
wanting their oddly behaving relativeto be
declared incompetent?